Nursing Elites

1. Mr. G has been admitted to the hospital with a head injury after a 12-foot fall. Which of the following nursing interventions is most appropriate when monitoring intracranial pressure?

• A. Administer hypotonic solutions
• B. Keep the head of the bed elevated
• C. Increase the client's core body temperature to 99.9 degrees
• D. Administer corticosteroids as ordered

Correct answer: D

Rationale: Administering corticosteroids as ordered is appropriate when monitoring intracranial pressure in clients at risk of increased pressure to reduce brain tissue swelling. Elevating the head of the bed helps in managing intracranial pressure by promoting venous drainage. Administering hypertonic solutions is used to reduce brain edema and control intracranial pressure. Increasing the client's core body temperature is not recommended as it can exacerbate brain injury. Corticosteroids are not routinely used for all head injuries but may be indicated in specific cases, such as certain types of brain injuries where swelling needs to be controlled.

2. Which of the following screening tools have been found to have high diagnostic accuracy for screening for intimate partner violence?

• A. Hurt, Insult, Threaten, and Scream (HITS)
• B. Humiliation, Afraid, Rape, and Kick (HARK)
• C. Slapped, Threatened, and Thrown (STaT)
• D. All of the above

Correct answer: D

Rationale: All of the above screening tools, including HITS, HARK, and STaT, have been found to have high diagnostic accuracy for screening intimate partner violence, as per the National Preventive Services Task Force. These tools are effective in identifying current or recent intimate partner violence. While the Partner Violence screen may have some predictive value for future intimate partner violence, the question specifically focuses on screening tools with high diagnostic accuracy, making 'All of the above' the correct choice. Choices A, B, and C are specific validated screening tools for intimate partner violence, each with its own set of questions that have been shown to be effective in identifying individuals experiencing intimate partner violence. Therefore, 'All of the above' is the most comprehensive and accurate choice for this question.

3. A nurse is providing dismissal instructions for a child who was admitted for rotavirus. Which of the following statements by the parent indicates the need for further teaching?

• A. I'll start giving him his antibiotics as soon as we get home.
• B. I will call the physician if he becomes dizzy or overly fussy.
• C. He will need to wash his hands a lot to keep this from spreading.
• D. I'll watch to see when he stops having diarrhea stools.

Correct answer: A

Rationale: The correct answer is 'I'll start giving him his antibiotics as soon as we get home.' Rotavirus is a viral illness, and antibiotics are ineffective for its treatment. The parent's statement indicates a need for further teaching as antibiotics are not appropriate for treating rotavirus. Option B is correct as it demonstrates the parent's understanding of when to contact the physician for concerning symptoms. Option C is a correct statement regarding infection control practices. Option D is also correct as monitoring diarrhea stools is essential to track recovery from rotavirus.

4. A client asks a nurse, 'Do you think I should move back home after this procedure?' and the nurse responds by saying, 'Do you think you should move back home?' What type of therapeutic communication is the nurse representing?

• A. Observation
• B. Reflection
• C. Summarizing
• D. Validating

Correct answer: B

Rationale: The nurse is demonstrating the therapeutic communication technique of reflection. In this scenario, the nurse is redirecting the question back to the client, encouraging them to explore their thoughts and feelings about the situation. Reflection involves restating a statement or question in a way that prompts the client to consider their own answers, fostering self-awareness and insight. Observation involves stating facts, summarizing involves condensing information, and validating involves confirming the client's feelings or experiences, none of which are demonstrated in this interaction.

5. While caring for a client in labor, a nurse attaches an electronic fetal monitor to the client's abdomen to assess the baby's heart rate. The nurse observes that the baby's heart rate slows down during each contraction and does not return to normal limits until after the contraction is complete. What type of fetal heart rate change does this pattern describe?

• A. Variable decelerations
• B. Late decelerations
• C. Early decelerations
• D. Accelerations

Correct answer: B

Rationale: Late decelerations are characterized by the baby's heart rate declining in utero during contractions. The heart rate drops below baseline and stays low until after the contraction ends. Late decelerations are concerning as they indicate uteroplacental insufficiency, which can compromise fetal oxygenation. This pattern is a non-reassuring sign and requires immediate intervention. Variable decelerations are typically abrupt decreases in heart rate, often associated with cord compression. Early decelerations, on the other hand, mirror the contractions and are considered benign, resulting from fetal head compression. Accelerations are reassuring signs of fetal well-being, indicating a responsive and healthy fetal nervous system.

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